This article describes the development and empirical status of guided Internet-delivered self-help. The treatment approach combines the benefits of bibliotherapy with book-length text materials and the support given online via web pages and e-mail. Interactive features such as online registrations, tests, and online discussion forums are also included. Cognitive behavior therapy (CBT) guided the research and clinical implementations of this approach, as it lends itself more easily to the self-help format compared with other presently available psychotherapy approaches. We include an overview of the research, current issues and research in service delivery, lessons learned through a program of research, and directions for future investigations.

Background: Major depression can be treated by means of cognitive-behavioural therapy, but as skilled therapists are in short supply there is a need for self-help approaches. Many individuals with depression use the internet for discussion of symptoms and to share their experience. Aims: To investigate the effects of an internet-administered self-help programme including participation in a monitored, web-based discussion group, compared with participation in web-based discussion group only. Method: A randomised controlled trial was conducted to compare the effects of internet-based cognitive-behavioural therapy with minimal therapist contact (plus participation in a discussion group) with the effects of participation in a discussion group only. Results: Internet-based therapy with minimal therapist contact, combined with activity in a discussion group, resulted in greater reductions of depressive symptoms compared with activity in a discussion group only (waiting-list control group). At 6 months' follow-up, improvement was maintained to a large extent. Conclusions: Internet-delivered cognitive-behavioural therapy should be pursued further as a complement or treatment alternative for mild-to-moderate depression.

Linköping University, Department of Behavioural Sciences and Learning, Clinical and Social Psychology. Linköping University, Faculty of Arts and Sciences.

Carlbring, Per

Linköping University, Department of Behavioural Sciences and Learning, Clinical and Social Psychology. Linköping University, Department of Behavioural Sciences and Learning, Cognition, Development and Disability. Linköping University, Faculty of Arts and Sciences.

In this commentary, we discuss the implications of the findings by Berger, Hohl, and Casper (this issue) together with the emerging database on the effects of Internet treatment for social anxiety disorder (social phobia). Their article is the third independent replication of guided Internet treatment of social anxiety disorder, and in this article, we comment on future research challenges and if Internet treatment now can be regarded as ready for dissemination into regular clinical settings.

With the advent of guided self-help via the Internet it has become increasingly important to investigate predictors of treatment outcome. The present study analyzed predictors of outcome using data from a randomized controlled trial on panic disorder [Carlbring, P. et al. (2005). Treatment of panic disorder: Live therapy versus self-help via Internet. Behaviour Research and Therapy, 43, 1321-1333]. Half of the sample received therapist guided Internet treatment (N = 25) and the other half face to face treatment (N = 24) in individual sessions during a 10-week study period. Results showed that agoraphobic avoidance was predictive of outcome in the face to face treatment, but not in the Internet treatment. A self-report screening of personality disorder (anxious cluster) was associated with worse outcome for the Internet treatment, but surprisingly associated with better outcome in face to face treatment. Cognitive capacity as measured by a test of verbal fluency was not predictive of outcome in the Internet group, and neither was a rating of treatment credibility. Overall, we conclude that in relation to face to face treatment different predictors of outcome should be investigated for Internet treatment. Internet treatment might be more suitable for certain clients who might benefit from remote treatment in the early phase of treatment.

Sixty-four individuals with social phobia (social anxiety disorder) were assigned to a multimodal cognitive-behavioral treatment package or to a waiting list control group. Treatment consisted of a 9-week, Internet-delivered, self-help program that was combined with 2 group exposure sessions in real life and minimal therapist contact via e-mail. Results were analyzed on an intention-to-treat basis, including all randomized participants. From pre- to posttest, treated participants in contrast to controls showed significant improvement on most measured dimensions (social anxiety scales, general anxiety and depression levels, quality of life). The overall within- and between-groups effect sizes were Cohen's d = 0.87 and 0.70, respectively. Treatment gains were maintained at 1-year follow-up. The results from this study support the continued use and development of Internet-distributed, self-help programs for people diagnosed with social phobia. Copyright 2006 by the American Psychological Association.

The Internet has revolutionized access to health information and made communication over long distances easier. This article reviews the use of the Internet for delivery of cognitive behaviour therapy. As a starting point the concept of guided self-help is introduced. We next present the treatment approach and different protocols briefly. Next, Swedish studies on panic disorder, social phobia, and depression are summarized using meta-analytic techniques. Implementation in regular clinical setting is discussed with a focus on efficacy versus effectiveness, training of therapist, combined treatments and cost-effectiveness. We conclude that Internet treatment is likely to become a treatment option for suitable patients in the future.

Internet-delivered cognitive behaviour therapy commonly consists of disorder-specific modules that are based on face-to-face manuals. A recent development in the field is to tailor the treatment according to patient profile, which has the potential to cover comorbid conditions in association with anxiety and mood disorders. However, it could be that the patients themselves are able to decide what modules to use. The authors tested this in an open pilot trial with 27 patients with mixed anxiety disorders. Modules were introduced with a brief description, and patients could choose which modules to use. The exception was the two first modules and the last, which involved psychoeducation and relapse prevention. The treatment period lasted for 10 weeks. Results showed large within-group effect sizes, with an average Cohen's d of 0.88. In a structured clinical interview, a majority (54%) had significantly improved 10 weeks after commencing treatment. Only one person dropped out. On the basis of results of this preliminary study, the authors suggest that the role of choice and tailoring should be further explored in controlled trials and that patient choice could be incorporated into Internet-delivered treatment packages.

BackgroundInternet-delivered cognitive behavior therapy (ICBT) for major depression has been tested in several trials, but only with follow-ups up to 1.5 years.

AimThe aim of this study was to evaluate the outcome of ICBT 3.5 years after treatment completion.Methods

A total of 88 people with major depression were randomized to either guided self-help or e-mail therapy in the original trial. One-third was initially on a waiting-list. Treatment was provided for eight weeks and in this report long-term follow-up data were collected. Also included were data from post-treatment and six-month follow-up. A total of 58% (51/88) completed the 3.5-year follow-up. Analyses were performed using a random effects repeated measures piecewise growth model to estimate trajectory shape over time and account for missing data.

ResultsResults showed continued lowered scores on the Beck Depression Inventory (BDI). No differences were found between the treatment conditions. A large proportion of participants (55%) had sought and received additional treatments in the follow-up period. A majority (56.9%) of participants had a BDI score lower than 10 at the 3.5-year follow-up.

ConclusionsPeople with mild to moderate major depression may benefit from ICBT 3.5-years after treatment completion.

With the advent of the Internet, delivered assessment applications are likely to make a difference in clinical psychology and in health care in general. The purpose of the present paper was to present an overview of the authors' experience regarding Internet administration of diagnostic interviews, questionnaires, and information processing tests. A conclusion is made that psychiatric assessments via the Internet are not yet to be recommended, but that questionnaire assessments are likely to generate equivalent or even superior data quality than traditional paper and pencil administration. Finally, the use of Internet-delivered tests of information processing is commented upon. Although these tests have been influential in theory development in clinical psychology, large-scale dissemination of tests has been slowed down by the need for laboratory facilities. Internet administration can provide new opportunities to administer tests from the patient's own home.

BACKGROUND: Internet-administered cognitive behavioural therapy (ICBT) has been found to be effective for a range of anxiety disorders. However, most studies have focused on one specific primary diagnosis and co-morbidity has not been considered. In primary care settings, patients with anxiety often suffer from more than one psychiatric condition, making it difficult to disseminate ICBT for specific conditions. The aim of this study will be to investigate if ICBT tailored according to symptom profile can be a feasible treatment for primary care patients with anxiety disorders. It is a randomised controlled trial aimed to evaluate the treatment against an active control group. METHODS: Participants with anxiety disorders and co-morbid conditions (N = 128), will be recruited from a primary care population. The Clinical Outcome in Routine Evaluation (CORE-OM) will serve as the primary outcome measure. Secondary measures include self-reported depression, anxiety, quality of life and loss of production and the use of health care. All assessments will be collected via the Internet and measure points will be baseline, post treatment and 12 months post treatment. DISCUSSION: This trial will add to the body of knowledge on the effectiveness of ICBT for anxiety disorders in primary care. The trial will also add knowledge on the long term effects of ICBT when delivered for regular clinic patients Trial registration: Clinical trials identifier NCT01390168.

Pathological gambling is a public health problem. Two percent of the Swedish general population has an ongoing gambling problem. Although pathological gambling is associated with depression, anxiety and low quality of life, few sufferers seek treatment. Barriers to accessing expert assistance include shortage of skilled therapists, long waiting lists, cost and sometimes even shame. A major challenge therefore, is to increase the accessibility and affordability of evidence-based psychological treatments. Printed self-help manuals have been developed to assist people with mental health problems who are unwilling or unable to access professional assistance, although there has been little evaluation of their efficacy. A modern alternative to printed self-help manuals is computers. In an attempt to provide a cost-effective treatment for problem and pathological gambling, a randomized controlled trial was conducted. Thirty participants were randomized to either a waiting list or an 8-week internet-based treatment program with minimal therapist contact via e-mail. Each participant also had a weekly 10-minute telephone conversation with a therapist. The web-based treatment program will be presented as well as the preliminary results from the study.

32.

Carlbring, Per

Linköping University, Faculty of Arts and Sciences. Linköping University, Department of Behavioural Sciences and Learning, Clinical and Social Psychology.

Internet-delivered guided cognitive behaviour therapy for social anxiety disorder has been found to generate promising short-term results, up to one year posttreatment. No study has however documented longer follow-up periods. In this 30-month follow-up we contacted 57 participants from the original study of which 77.2% (44/57) responded to the Internet-administered outcome measures and 66.7% (38/57) completed a telephone interview. Results showed large pretreatment to follow-up within-group effect sizes for the primary outcome measures (Cohens d 1.10-1.71), and a majority (68.4%; 26/38) reported improvements in the interview. The findings suggest that the long-term effects seen in previous live treatment CBT trials can occur in Internet-delivered treatment as well.

This experimental analog component study compared two ways of administrating relaxation, either via a computer or by a therapist. The second phase of applied relaxation was used, which is called “release-only relaxation”. Sixty participants from a student population were randomized to one of three groups: computer-administered relaxation, therapist-administered relaxation, or a control group in which participants surfed on the Internet. Outcome was measures using psychophysiological responses and self-report. Objective psychophysiological data and results on the subjective visual analogue scale suggest that there was no difference between the two forms of administration. Both experimental groups became significantly more relaxed than the control group that surfed on the Internet. Practical applications and future directions are discussed.

Objective: This study evaluated a 10-week Internet-based bibliotherapy self-help program with short weekly telephone calls for people suffering from panic disorder with or without agoraphobia. Method: After the authors confirmed the diagnosis by administering the Structured Clinical Interview for DSM-IV by telephone, 60 participants were randomly assigned to either a wait-listed control group or a multimodal treatment package based on cognitive behavior therapy plus minimal therapist contact via e-mail. A 10-minute telephone call was made each week to support each participant. Total mean time spent on each participant during the 10 weeks was 3.9 hours. The participants were required to send in homework assignments before receiving the next treatment module. Results: Analyses were conducted on an intention-to-treat basis, which included all randomly assigned participants. From pretreatment to posttreatment, all treated participants improved significantly on all measured dimensions (bodily interpretations, maladaptive cognitions, avoidance, general anxiety and depression levels, and quality of life). Treatment gains on self-report measures were maintained at the 9-month follow-up. A blind telephone interview after the end of treatment revealed that 77% of the treated patients no longer fulfilled the criteria for panic disorder, whereas all of the wait-listed subjects still suffered from it. Conclusions: This study provides evidence to support the use of treatment distributed via the Internet with the addition of short weekly telephone calls to treat panic disorder. Replication should be made to compare self-help and telephone treatment based on cognitive behavior methods with nonspecific interventions.

This study
evaluated a nine-week Internet-based self-help program for people
suffering from social phobia. After confirming the diagnosis with a
structured clinical interview for the DSM-IV (SCID) by telephone,
26 participants were treated with a multimodal treatment package
based on cognitive behavioral therapy plus weekly therapist contact
via e-mail.
Results were analyzed on a basis of intention-to-treat. There were
no differences between the two pre-treatment assessment points.
However, from pre- to post-test, treated participants improved
signi?cantly on all measured dimensions (social anxiety, general
anxiety, depression levels, and quality of life). The overall
within-group effect size measured with Cohen-s d was d=0.88.
Treatment gains were maintained or improved at the 6-month
follow-up (Cohen-s d=1.31). The results of this study support
the continued use and development of Internet-distributed self-help
programs for people diagnosed with social
phobia.

49.

Carlbring, Per

et al.

Linköping University, Faculty of Arts and Sciences. Linköping University, Department of Behavioural Sciences and Learning, Clinical and Social Psychology.

Gunnarsdottir, M.

Gunnarsdóttir, M., Uppsala University, Uppsala, Sweden.

Hedensjo, L.

Hedensjö, L., Uppsala University, Uppsala, Sweden.

Andersson, Gerhard

Linköping University, Faculty of Arts and Sciences. Linköping University, Department of Behavioural Sciences and Learning, Clinical and Social Psychology.

Background: Although effective therapies for social phobia exist, many individuals refrain from seeking treatment owing to the embarrassment associated with help-seeking. Internet-based cognitive-behavioural self-help can be an alternative, but adherence is a problem. Aims: To evaluate a 9-week programme of internet-based therapy designed to increase treatment adherence by the addition of short weekly telephone calls, nine in all, with a total duration of 95 min. Method: In a randomised controlled trial the effects of internet-based cognitive-behavioural therapy in the treatment group (n=29) were compared with a waiting-list control group (n=28). Results: Compared with the control group the treated participants experienced greater reductions on measures of general and social anxiety, avoidance and depression. Adherence to treatment was high, with 93% finishing the complete treatment package. One year later all improvements were maintained. Conclusions: This study provides evidence to support the use of internet-based treatment supplemented by short, weekly telephone calls.